The recent clash between Congress Party and Aam Aadmi Party (AAP) about Mohalla clinics in Delhi is symptomatic of our media’s obsession with politics as a spectator sport, and reluctance to generate meaningful and healthy discussion on issues that matter. Instead we would do well to focus on improving primary and family healthcare.
Among large economies, public expenditure on healthcare is lowest in India. Union and States put together, our governments are spending about 1.2% of GDP on healthcare – about a third of it by the Union, and two-thirds by the States. The recent claims of sudden increase in government health expenditure are misleading, as the budget allocations on water supply, sanitation and nutrition are simply added to health expenditure, and inflated figures of 2.1% of GDP are shown. About 70% of expenditure on healthcare is private, and most of it is out-of-pocket (OOP). This OOP expenditure is growing fast. Vast number of people do not have access to quality healthcare. About 90% of our workers are in the unorganised sector, most of them eking out precarious livelihoods. Sickness for the poor and lower-middle classes can be devastating. A sick person cannot work and earn money. Medical care, in the face of poor public facilities, is costly. Private health insurance is limited largely to the organised sector. Even those covered by insurance, ESI, or government risk-pooling programmes like Aayushman Bharat often have to pay for out-patient services.
Most out-patients (85%) go to private doctors. About 60% of in-patient care is in the private sector. Poor access to quality healthcare and high OOP expenditure are hurting low-income families. About 5 crore people are descending into poverty every year on account of ill health. Recent efforts to expand hospital care for the poor, like Aayushman Bharat, Aarogyasri etc, are welcome and necessary. Much more needs to be done to expand free hospital care to all ailments and build a viable universal healthcare system.
Primary and out-patient care is particularly inadequate in India. Most people in villages either suffer silently from illness until it cannot be ignored, or forced to go to an unqualified, informal local health provider. Public hospitals in cities are overcrowded. AIIMS, New Delhi receives about 12000 out-patients a day, a world record. Apex healthcare institutions and teaching hospitals are essentially meant for referral and tertiary care. But in the absence of effective primary care, even patients with simple ailments that do not require hospital care flock to district and teaching hospitals. Established government teaching hospitals receive 4000-6000 out-patients a day.
Quality out-patient and family care is the vital foundation of a healthcare system. Most ailments can be addressed at a low-cost with a good family care system. In the absence of good family care, patients do not seek medical attention in time, and delays often lead to complications and high-cost hospital interventions which could have been avoided. Our epidemiological profile is changing. Whereas most patients in India suffered from infectious diseases decades ago, now incidence of non-communicable diseases like diabetes, hypertension, arthritis, kidney disease, heart disease and cancer is rising. A recent Lancet study shows that about 11% of all adults are diabetic and 15% are pre-diabetic. Most of these 24 crore people do not get proper care and treatment. These cases can be managed easily locally at a low-cost in family clinics. In the absence of proper family care, most such cases are neglected, and cause serious illness over time that requires high-cost hospital intervention. In many such cases the damage done is irreversible, and sometimes fatal. Early diagnosis and proper management and treatment saves lives, ensures good health and saves money.
Delhi government’s Mohalla clinic model is a step forward. Over 500 clinics have been established for a population of 1.9 crore, or one clinic per 40,000 populations. Patients with simple ailments can go to a nearby clinic for out-patient treatment. Simple diagnostics are available in the clinic, and drugs are dispensed. The doctors and other staff are paid on a free-for-service model, getting a fixed sum of money for each out-patient.
The Delhi model is a good start. We need a much more robust and innovative model for effective family care all over India. We need one family care physician for every 15,000 population to have reasonable quality care. A pool of doctors should be available in a small town, each doctor having their own clinic under the publicly-funded family care system. Patients should have choice and should be free to go to any of the physicians in the pool. The physician gets a fixed fee for each out-patient treated. There will be competition among physicians to attract patients, as their income depends on their reputation and trust of patients.
A pool of 10 physicians will typically see about 500 outpatients in a day, catering to a population of 1 to 1.5 lakhs in all surrounding areas and villages. There should be free diagnostics – simple tests in a local laboratory, and more sophisticated tests for which samples can be pooled in a bigger city within the district. Andhra Pradesh has an excellent free diagnostic model, which can be adapted. A dispensary will dispense prescribed drugs free of cost. Tamil Nadu has an effective drug distribution system that can be replicated. Such pooling and public-private-partnership will ensure better access – within 10 km for most villages and within 2 km in towns and cities. Pooling ensures choice and competition, and therefore accountability and quality care are assured. Economies of scale with pooling bring down cost of diagnostics and drug dispensing.
Such a system for the whole country will cost about 30,000 cores, or about 0.1% of GDP. It will need only about 100,000 doctors. We have 14 lakh doctors registered, and we are producing nearly one lakh doctors every year. India has many advantages in improving healthcare at a low-cost. We should realise that improvement of healthcare is vital to eliminate poverty and enhance productivity.
A lot needs to be done to improve healthcare. But building a good quality, accessible primary and family care system is a good starting point.
The author is the founder of Lok Satta movement and Foundation for Democratic Reforms. Email: firstname.lastname@example.org / Twitter@jp_loksatta